ONLINE PRE-REGISTRATION
   
  • If this is an emergency, please call 911.
  • Online pre-registration must be submitted at-least 48 hours in advance of visit. Please bring photo ID, insurance card(s) and advance directive (if applicable) on day of service.
  • To pre-register by phone please call registration department at (270)706-5708.
  • Do not refresh this page.
PATIENT INFORMATION
First name *
Last name *
MI
Date of birth * mm/dd/yyyy
Sex *
Which of the Following Racial Categories Applies to You? *
If selected Other race above, please explain
What is your Ethnic Heritage? *
Marital status *
Social security number *
Religious preference
Address *
City *
State *
Zipcode *
Phone number * xxx-xxx-xxxx
Email  
Employer *
e.g. Company name, Unemployed, Retired.
Employer address
Employer city
Employer state
Employer zipcode
Employer phone number xxx-xxx-xxxx
 
VISIT INFORMATION
Procedure/Test *
e.g. CT, EKG, MRI, LAB, Surgery, Maternity.
Scheduled date (mm/dd/yyyy) *
Note: If maternity patient, use due date.
Scheduled time
Latex allergic?
Advance directive?
Please bring on day of service if yes.
Ordering physician *
Family physician
Primary care physician
 
RESPONSIBLE PARTY, IF PATIENT IS UNDER 18 YEARS OF AGE
First name
Last name
Address
City
State
Zipcode
Phone number xxx-xxx-xxxx
Employer
Employer address
Employer city
Employer state
Employer zipcode
Employer phone number xxx-xxx-xxxx
 
IF VISIT IS ACCIDENT RELATED
Accident date (mm/dd/yyyy)
Accident time
Accident location
Accident/Injury description
 
EMERGENCY CONTACT INFORMATION
Emergency contact name *
Relation to patient *
Emergency contact phone * xxx-xxx-xxxx
2nd emergency contact name
Relation to patient
2nd emergency contact phone xxx-xxx-xxxx
 
INSURANCE INFORMATION
Primary insurance name *
e.g. Insurance name, None.
Name as it appears on card
Card holder ID/Member #
Card holder social security #
Card holder relation to patient
Plan number
Group number
Insurance address
City
State
Zipcode
Insurance phone xxx-xxx-xxxx
Secondary insurance name
Name as it appears on card
Card holder ID/Member #
Card holder social security #
Card holder relation to patient
Plan number
Group number
Insurance address
City
State
Zipcode
Insurance phone xxx-xxx-xxxx
 
CLARIFICATION CONTACT INFORMATION
Phone number to reach * xxx-xxx-xxxx
Speak only to patient? *
Others we can speak to